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Mescher C, Gilbertson D, Randall NM, Tarchand G, Tomaska J, Baumann Kreuziger L, Morrison VA. The impact of Agent Orange exposure on prognosis and management in patients with chronic lymphocytic leukemia: a National Veteran Affairs Tumor Registry Study. Leuk Lymphoma 2017; 59:1348-1355. [PMID: 28905668 DOI: 10.1080/10428194.2017.1375109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Exposure to Agent Orange (AO) has been associated with the development of chronic lymphocytic leukemia (CLL). We performed a retrospective study of 2052 Vietnam veterans identified in the National VA Tumor Registry to assess the impact of AO exposure on CLL prognosis, treatment and survival. Prognostic factors did not differ based on exposure. Veterans exposed to AO were diagnosed younger (63.2 vs. 70.5 years, p < .0001) and had longer overall survival (median not reached vs. 91 months, p < .001). This prolonged survival was in the subgroups of patients aged 60-69 years (p< .0001) and those with 11q deletion (p < .0001). Those exposed to AO were more likely to be treated with fludarabine, chlorambucil and rituximab (38 vs. 21%, p < .001) and bendamustine plus rituximab (25 vs. 18%, p = 0.039) as first line therapy. Exposure to AO was not associated with either poor prognostic factors or shortened overall survival in our large veteran population with CLL.
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Affiliation(s)
- Craig Mescher
- a Division of Hematology, Oncology and Transplant , University of Minnesota , Minneapolis , MN , USA
| | - David Gilbertson
- b Chronic Disease Research Group , Minneapolis Medical Research Foundation , Minneapolis , MN , USA
| | - Nicole M Randall
- c Indiana Hemophilia & Thrombosis Center , Indianapolis , IN , USA
| | | | - Julie Tomaska
- d Veterans Affairs Medical Center , Minneapolis , MN , USA
| | - Lisa Baumann Kreuziger
- e Blood Center of Wisconsin , Milwaukee , WI , USA.,f Department of Medicine, Division of Hematology , Medical College of Wisconsin , Minneapolis , MN , USA
| | - Vicki A Morrison
- g Hematology/Oncology & Infectious Disease , University of Minnesota , Minneapolis , MN , USA.,h Hennepin County Medical Center , Minneapolis , MN , USA
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Dysken MW, Guarino PD, Vertrees JE, Asthana S, Sano M, Llorente M, Pallaki M, Love S, Schellenberg GD, McCarten JR, Malphurs J, Prieto S, Chen P, Loreck DJ, Carney S, Trapp G, Bakshi RS, Mintzer JE, Heidebrink JL, Vidal-Cardona A, Arroyo LM, Cruz AR, Kowall NW, Chopra MP, Craft S, Thielke S, Turvey CL, Woodman C, Monnell KA, Gordon K, Tomaska J, Vatassery G. Vitamin E and memantine in Alzheimer's disease: clinical trial methods and baseline data. Alzheimers Dement 2014; 10:36-44. [PMID: 23583234 PMCID: PMC4128187 DOI: 10.1016/j.jalz.2013.01.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 01/06/2013] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) has been associated with both oxidative stress and excessive glutamate activity. A clinical trial was designed to compare the effectiveness of (i) alpha-tocopherol, a vitamin E antioxidant; (ii) memantine (Namenda), an N-methyl-D-aspartate antagonist; (iii) their combination; and (iv) placebo in delaying clinical progression in AD. METHODS The Veterans Affairs Cooperative Studies Program initiated a multicenter, randomized, double-blind, placebo-controlled trial in August 2007, with enrollment through March 2012 and follow-up continuing through September 2012. Participants with mild-to-moderate AD who were taking an acetylcholinesterase inhibitor were assigned randomly to 2000 IU/day of alpha-tocopherol, 20 mg/day memantine, 2000 IU/day alpha-tocopherol plus 20 mg/day memantine, or placebo. The primary outcome for the study is the Alzheimer's Disease Cooperative Study/Activities of Daily Living Inventory. Secondary outcome measures include the Mini-Mental State Examination; the Alzheimer's Disease Assessment Scale, cognitive portion; the Dependence Scale; the Neuropsychiatric Inventory; and the Caregiver Activity Survey. Patient follow-up ranged from 6 months to 4 years. RESULTS A total of 613 participants were randomized. The majority of the patients were male (97%) and white (86%), with a mean age of 79 years. The mean Alzheimer's Disease Cooperative Study/Activities of Daily Living Inventory score at entry was 57 and the mean Mini-Mental State Examination score at entry was 21. CONCLUSION This large multicenter trial will address the unanswered question of the long-term safety and effectiveness of alpha-tocopherol, memantine, and their combination in patients with mild-to-moderate AD taking an acetylcholinesterase inhibitor. The results are expected in early 2013.
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Affiliation(s)
| | - Peter D Guarino
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Julia E Vertrees
- VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Sanjay Asthana
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Mary Sano
- Bronx Veterans Medical Research Center, New York, NY, USA
| | | | | | - Susan Love
- VA Minneapolis Health Care System, Minneapolis, MN, USA
| | | | | | | | | | - Peijun Chen
- Louis Stokes Cleveland VAMC, Cleveland, OH, USA
| | - David J Loreck
- VA Maryland Healthcare System, University of Maryland Medical School, Department of Psychiatry, Baltimore, MD, USA
| | - Sara Carney
- VA Maryland Healthcare System, Baltimore, MD, USA
| | - George Trapp
- VA North Texas Healthcare System, Dallas, TX, USA
| | | | - Jacobo E Mintzer
- Ralph H. Johnson VAMC, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | - Angel R Cruz
- Bay Pines VA Healthcare System, Bay Pines, FL, USA
| | | | | | - Suzanne Craft
- VA Puget Sound Healthcare System, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Stephen Thielke
- VA Puget Sound Healthcare System, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Julie Tomaska
- VA Minneapolis Health Care System, Minneapolis, MN, USA
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Dysken MW, Sano M, Asthana S, Vertrees JE, Pallaki M, Llorente M, Love S, Schellenberg GD, McCarten JR, Malphurs J, Prieto S, Chen P, Loreck DJ, Trapp G, Bakshi RS, Mintzer JE, Heidebrink JL, Vidal-Cardona A, Arroyo LM, Cruz AR, Zachariah S, Kowall NW, Chopra MP, Craft S, Thielke S, Turvey CL, Woodman C, Monnell KA, Gordon K, Tomaska J, Segal Y, Peduzzi PN, Guarino PD. Effect of vitamin E and memantine on functional decline in Alzheimer disease: the TEAM-AD VA cooperative randomized trial. JAMA 2014; 311:33-44. [PMID: 24381967 PMCID: PMC4109898 DOI: 10.1001/jama.2013.282834] [Citation(s) in RCA: 347] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Although vitamin E and memantine have been shown to have beneficial effects in moderately severe Alzheimer disease (AD), evidence is limited in mild to moderate AD. OBJECTIVE To determine if vitamin E (alpha tocopherol), memantine, or both slow progression of mild to moderate AD in patients taking an acetylcholinesterase inhibitor. DESIGN, SETTING, AND PARTICIPANTS Double-blind, placebo-controlled, parallel-group, randomized clinical trial involving 613 patients with mild to moderate AD initiated in August 2007 and concluded in September 2012 at 14 Veterans Affairs medical centers. INTERVENTIONS Participants received either 2000 IU/d of alpha tocopherol (n = 152), 20 mg/d of memantine (n = 155), the combination (n = 154), or placebo (n = 152). MAIN OUTCOMES AND MEASURES Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS-ADL) Inventory score (range, 0-78). Secondary outcomes included cognitive, neuropsychiatric, functional, and caregiver measures. RESULTS Data from 561 participants were analyzed (alpha tocopherol = 140, memantine = 142, combination = 139, placebo = 140), with 52 excluded because of a lack of any follow-up data. Over the mean (SD) follow-up of 2.27 (1.22) years, ADCS-ADL Inventory scores declined by 3.15 units (95% CI, 0.92 to 5.39; adjusted P = .03) less in the alpha tocopherol group compared with the placebo group. In the memantine group, these scores declined 1.98 units less (95% CI, -0.24 to 4.20; adjusted P = .40) than the placebo group's decline. This change in the alpha tocopherol group translates into a delay in clinical progression of 19% per year compared with placebo or a delay of approximately 6.2 months over the follow-up period. Caregiver time increased least in the alpha tocopherol group. All-cause mortality and safety analyses showed a difference only on the serious adverse event of "infections or infestations," with greater frequencies in the memantine (31 events in 23 participants) and combination groups (44 events in 31 participants) compared with placebo (13 events in 11 participants). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate AD, 2000 IU/d of alpha tocopherol compared with placebo resulted in slower functional decline. There were no significant differences in the groups receiving memantine alone or memantine plus alpha tocopherol. These findings suggest benefit of alpha tocopherol in mild to moderate AD by slowing functional decline and decreasing caregiver burden. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00235716.
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Affiliation(s)
| | - Mary Sano
- James J. Peters VA Medical Research Center, New York, New York
| | - Sanjay Asthana
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Julia E Vertrees
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Muralidhar Pallaki
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio6Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Susan Love
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | | | | | | | | | - Peijun Chen
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio6Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David J Loreck
- VA Maryland Healthcare System, Baltimore11University of Maryland Medical School, Department of Psychiatry, Baltimore
| | | | | | - Jacobo E Mintzer
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina14Department of Health Studies, Medical University of South Carolina, Charleston15Roper St Francis Healthcare, Charleston, South Carolina
| | | | | | | | - Angel R Cruz
- Bay Pines VA Healthcare System, Bay Pines, Florida
| | | | | | | | - Suzanne Craft
- VA Puget Sound Health Care System, Seattle, Washington21Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Stephen Thielke
- VA Puget Sound Health Care System, Seattle, Washington21Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Carolyn L Turvey
- Iowa City VA Medical Center, Iowa City, Iowa23University of Iowa, Iowa City
| | - Catherine Woodman
- Iowa City VA Medical Center, Iowa City, Iowa23University of Iowa, Iowa City
| | | | - Kimberly Gordon
- W. G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
| | - Julie Tomaska
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Yoav Segal
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Peter N Peduzzi
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven26Yale University School of Public Health, New Haven, Connecticut
| | - Peter D Guarino
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven26Yale University School of Public Health, New Haven, Connecticut
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